What's Best for Kindergartner with ADHD?

I am an educator and I’m currently working with a kindergartner with what could best be described as extreme ADHD. She is currently on Ritalin, which has allowed her to increase her attention span. However, it seems the medication makes her moody, tired and melancholy. Ritalin also seems to greatly alter her personality. She seems almost depressed when she is on the drug. Are there any interventions that would be helpful in such a case? Her parents seem receptive to advice and would really love to help this little girl.

We certainly can’t offer diagnoses or treatment recommendations from such a distance, but can offer some general information in response to your observations, questions and concerns that will no doubt resonate with educators and parents across the country.

Because there still is no definitive objective test for diagnosing Attention Deficit Hyperactivity Disorder (ADHD), doctors making this diagnosis must rely on careful observation of children’s behavior in their offices as well as thorough reports from teachers and parents.

ADHD is probably over-diagnosed in some settings, and under-diagnosed in others, but either way, there is clearly room for error. There is good evidence that stimulant medication is an effective treatment for ADHD, but when it is not, it is important to go back to the drawing board to be sure that ADHD is the correct diagnosis, and whether or not it is the only one.

Many children are very, very active without tipping over into hyperactivity. This distinction can be difficult to make unless the hyperactivity is truly extreme.

In young children, there is a wide range in the ability to sit still and concentrate in the classroom setting, and indeed, we are asking more and more compliance with traditional academic demands at earlier and earlier ages, despite the fact that there is no reason to believe that children’s capacities to handle these have started developing at earlier ages. (In fact, there may be some conditions in our world today that make it harder for some children to attend and focus. For example, one study found a correlation between long hours of television watching in children under age 3 with symptoms of attention difficulties at age 7, although a cause and effect link could not be made by the researchers.)

Excessive physical activity, fidgeting and restlessness, trouble concentrating, being easily distracted and impulsive behavior all are symptoms of ADHD. Yet they also can be more general signs of distress in young children. Just as fever suggests an infection without telling us what the cause of the infection is, these behaviors in young children may signal a range of other conditions, including anxiety, a mood disorder or even post traumatic stress in a child who has been abused or traumatized in some other way.

Stimulants such as Ritalin (methylphenidate) can bring about clear improvements, noticeably increasing attention and concentration, and decreasing hyperactivity. Sometimes, though, a child does begin to appear down, or even depressed when taking these medications. They can interfere with sleep, which might also be a cause for sleepiness and moodiness during the day. A switch to a different preparation (short or long-acting, for example) or kind of stimulant (dexedrine, for example, rather than methylphenidate) sometimes can help with either of these side effects, although there are some children who just won’t be able to tolerate these medications. If the Ritalin is stopped and the melancholy moodiness continues, there may be another problem that needs careful assessment. If parents express concerns that line up with yours, they may accept your suggestion to turn to a child psychiatrist, if they haven’t done so already, to address these specific questions about possible side effects, other treatment options and diagnostic reassessment.

While there now are studies that show that medication alone can be more effective than cognitive-behavioral treatments alone for ADHD, there are also a number of other measures to try that may be helpful. In the classroom, a child who is easily distracted and has trouble attending should be seated close to the teacher, and positioned so that all of the other children wiggling and jiggling are out of her line of sight. This must be done without making her feel singled out or humiliated – self-esteem all too often suffers in children with ADHD. It is also helpful to give such children regular, gentle reminders to tune back in again: The teacher can work out a private signal with the child that helps the child to feel special and valued rather than to stand out as the “trouble” child.

Reminders and disciplines should be framed positively and with hope, since these children often need so many that they will soon tune out anything that sounds like nagging to protect themselves from feeling worse and worse about themselves.

Special chores that allow them to work off steam, like getting up to sharpen the pencils, or pass out supplies, or to deliver the attendance list to the principal’s office can also help honor such children’s need for extra activity. These children often need frequent encouragement, praise and rewards, as it can be as hard for them to sustain their own motivation and keep themselves on track independently.

Careful and respectful back and forth sharing between parents and teachers can help create a more seamless experience of rewards and reminders for the child as she adapts each day to transitions between school and home. The long-term goal is for the child to understand and accept herself so that she can become increasingly independent in coping with and overcoming her challenges. For parents and teachers to help with this, they too will need to understand and accept.

For more information:

Children and Adults with Attention Deficit/Hyperactivity Disorder www.chadd.org

The American Academy of Child and Adolescent Psychiatry’s website at www.aacap.org

Questions for Families Today can be submitted through this online form. Questions of general interest may be answered in this column, which may be posted on a Families Today web area or collected in book form. Drs. Brazelton and Sparrow regret that unpublished letters cannot be answered individually.

Responses to questions are not intended to constitute or to take the place of medical or psychiatric evaluation, diagnosis or treatment. If you have a question about your child’s health or well-being, consult your child’s health-care provider.

(Dr. T. Berry Brazelton heads the Brazelton Touchpoints Project, which promotes and supports community initiatives for families. Dr. Joshua Sparrow, a child psychiatrist, is director of Special Initiatives at the Brazelton Touchpoints Center. Learn more about the center at www.touchpoints.org.)